More Than Remote Success

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Now that technology concerns for many have basically run their course for picture archiving and communications systems (PACS), the focus has turned to creating value. As radiologists expand their volume of work and others seek subspecialty expertise through teleradiology, interest grows in maintaining a personal relationship with all members of a facility's electronic community, incorporating quality assurance measures and ensuring consistency and reliability throughout the system.

The Cleveland Clinic's environment encompasses satellite sites from Iowa to New Jersey. The system does 50,000 to 60,000 exams per year and includes eight family healthcare centers and approximately 20 freestanding imaging centers. Some sites are separate business entities with their own needs and solutions for image acquisition. The philosophy at Cleveland Clinic is what is good for the hospital is good for the clinics and other locations.

"Whether it's an MR or CT from an imaging center, [everything] should come to me in the same kind of manner with the same kind of information that I would expect it could come from one of the hospitals or one of the other locations that I dealt with," says David Piraino, M.D., a musculoskeletal radiologist and head of computers in radiology. "It's not an exception. It's the rule."

The approach at Cleveland Clinic dictates the integration of images into a practice and the incorporation of all scheduling and ordering information as well. "You not only have to have your PAC system there, but you also have to have your radiology information system (RIS), your whole information technology infrastructure, at your freestanding imaging centers just like you would have it in your hospital."

Cleveland Clinic uses a Siemens Medical Solutions PACS and an IDX Systems Corp. RIS. The system's server component is UNIX-based. The viewing component is either PC- or UNIX-based.

The freestanding clinics are doing mostly CT, MR and ultrasound and very little plain film. Most of the freestanding imaging centers Cleveland Clinic is associated with have not put in x-ray. The associated sites that have it are mostly imaging centers that are in the same building as a moderate-sized group practice of radiologists. General radiography is for the most part in the Clinic's family health centers, which usually contain between 10 and 30 doctors with offices there.

Piraino says that every year additional imaging centers join the system. The technology continues to meet the e-radiology group's needs. Of the thousands of exams handled each year, most  come from freestanding imaging centers.

The integration of both the RIS and PACS has been an important process in the success of the undertaking.

"Our business model said that we would not take on any business that didn't use both of those systems," Piraino says. "We thought that we couldn't provide the type of service that we needed to [without that integration]. The amount of integration [and shared information, including images, patient demographics and history, RIS reports, and the reason for the examination] between the two systems has increased over the five-year period. So they function more as a single system now than they did at the beginning."

With a widely distributed environment such as this one comes inherent special challenges. Having imaging centers across a large geographic region, the Clinic recognized the importance of maintaining a personal relationship across the imaging centers among radiologists, technologists, referring physicians, cardiologists and orthopedists. "It's important that you deal with the quality of that whole process from scheduling to image acquisition to transmission, interpretations to distribution of the report," Piraino says. "I think that's one of the most difficult things, and the information technology provides you the tool to help you to do that."

The Cleveland Clinic faced its own special business challenge in that its physicians are a group practice comprising the Cleveland Clinic Foundation; that is, no separate practice groups exist. It is all basically one large entity handling more than a million exams per year.

"The difficulty that we have had when we do freestanding imaging centers that are not what I would call local, is we try to involve local radiologists in the process and just the business issue of two kinds of different cultures - one is a private practice culture and one is a large group practice culture - integrating those and